As I See It

Who Should Remove Pediatric Cataracts?

Ego shouldn't get in the way of providing the best possible care.

By Paul S. Koch, MD, Editor Emeritus

Everyone has heard of Bob Sinskey. There's hardly a cataract surgeon practicing today who hasn't used a Sinskey Hook, a Sinskey Lens, or sipped some Sinskey wine. I know him as an influential pioneer in phacoemulsification, one of the first surgeons to move the operation from the anterior to the posterior chamber. I'm grateful he was a generous teacher.

Less well known was his passionate argument that cataract surgery in children should be done by surgeons knowledgeable and experienced in cataract surgery. In some cases this would be a skilled pediatric ophthalmologist, but he railed against cataract surgery performed by “pediatric ophthalmologists” who were, in reality, strabismus specialists. He spent the last few years of his career lecturing on this subject, angered by what he felt was bad pediatric cataract surgery performed by ophthalmologists whose expertise lay in moving muscles, not in microsurgery.

After he retired, no one else took up the reins. I suspect the fellowships beefed up their training, and peace settled on the specialty. All was well, or so I assumed.

Girl, Interrupted

And that brings us to the 12-year-old girl who inspired this column. I had performed cataract surgery on her mother at age 14 (her, not me). She later married, moved away, started a family and now had a daughter with a cataract. Her pediatrician referred her to a pediatric ophthalmologist in her new town who, I subsequently learned, pretty much exclusively did strabismus. Not confident in how to handle the cataracts, he told the girl's mom she was too young to have an operation. He wanted to wait a few more years.

All was well with her mild cataracts until about a year ago. She was happy and doing well in school. Then the cataract grew and school-work became difficult. First she couldn't see the blackboard, and soon her books either. Later, she couldn't play games and her classmates started to tease and make fun of her. Eventually she couldn't see well enough to recognize their faces. She became withdrawn and depressed and she needed antidepressant medications. And still her doctor told her parents he wanted to wait a few more years. When they finally took the trip down to visit me, her dad had to carry her because she couldn't see to walk easily.

She had white cataracts so dense I could not get a red reflex. “A few more years,” my ass.

The next week, I did her operation at my surgery center. She only needed some intravenous Versed (midazolam) and topical/intracameral anesthesia. In the recovery room, she made eye contact with her mom and dad for the first time in months. The next day a smiling, radiant, beautiful little girl bounded into the office.

I was happy to have changed her life, but furious it got that far because her parents were given terrible advice. Her other doctor watched her change from a normal schoolgirl into a depressed, isolated child who lost a year of her life. He didn't know what to do about her case, but still he did not ask for help.

I agree with Dr. Sinskey. Difficult and challenging cataract cases should be handled by surgeons skilled in cataract surgery, whether their practices be primarily pediatric or adult.

Would you want your 80-year-old mother to have cataract surgery by someone not comfortable with the procedure? Then what about your 12-year-old daughter, who is going to use her eyes for another 80 years? How do you decide what's best for her?

Know Your Limits, and Own Up to Them

I'm easily confused when it comes to retina, so I send those cases out. I don't know much about plastics either, so I refer those cases, too. None of us know everything, but happily we have colleagues we can ask. If this sweet little girl's pediatric ophthalmologist had swallowed his pride and asked for help, she would not have lost a year of her life. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His e-mail is paulkoch@kocheye.com.